Clinical Quality and Regulatory Specialist

Job Description: • Assures the highest standards of clinical quality and regulatory compliance across Utilization Management department activities for all government lines of business and delegated vendors. • Confirms Utilization Management’s compliance with federal, state, and regulatory guidelines (e.g., NCQA, CMS). • Assists with policies and procedures, and continually monitoring regulatory changes. • Collects, analyzes, and interprets clinical data, clinical outcomes, and performance metrics to prepare comprehensive reports and audit responses. • Collaborates across departments to resolve issues and provide education on regulatory requirements and best practices. Requirements: • Minimum Current license in one or more of the following disciplines: LCSW, LSW, LPC, or other related clinical license (OR) Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC). • 3-5 years’ experience in case management/managed care with specific knowledge of quality monitoring, compliance and/or regulatory processes. • 2 years experience with quality measurement systems. • 1 year experience evaluating, implementing or revising work processes. • Preferred Bachelor’s degree. • 3 or more years’ experience in performing auditing/monitoring functions. • 3 or more years’ experience creating tools, training documents and educational materials geared to adult learners. • 3 years’ experience with Microsoft Office products. • 3 or more years’ experience working in the health care/health insurance industry. • Quality Management System certification. Benefits: • Health insurance • 401(k) matching • Paid time off • Professional development opportunities Apply tot his job Apply To this Job